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Order in chaos: transforming best-of-breed solutions into integrated solutions. (Systems Integration).

With multiple "squeaky wheels" vying for attention and budget dollars, prioritizing information technology (IT) needs and projects can be challenging to say the least. Some needs are departmental, others enterprise-wide. Some are man dates from management, others from external pressures. And some are a mixture of all of the above.

At Sharp HealthCare, a regional, integrated healthcare delivery system in San Diego, finding commonality among issues and needs in order to strategically select investments and allocate resources has become our mantra.

Our IT strategy is straightforward: adopt innovative, cost-effective systems and processes that support clinical, administrative and service excellence. As such, we have been building a sophisticated IT infrastructure, comprised of best-of-breed information systems from various vendors. We believe this is an optimal approach, because it will arm our various end-user communities with the specialized tools and functionalities they require.

On the downside, though, we realized that the inability of these distinct systems to work together--particularly at the point of use--can be the source of many complex problems. From causing end user frustration and loss of productivity to creating potential gaps in patient safety, security and privacy, not to mention constantly draining our IT resources--systems incompatibility can be an Achilles heel.

Ease of Access, Ease of Use

Our hospital-based application portfolio is anchored by IDX for patient access, patient accounting, medical records and radiology, and augmented by other solutions including Cerner for laboratory, CliniComp for documentation and A4 (formerly EmStat) for the emergency department (ED). We are in the process of rolling out IDX CareCast for computerized physician order entry (CPOE), clinical data repository (CDR) and pharmacy, and we employ a Quovadx interface engine.

Currently, most order entry is performed by our nursing staff into an older IDX system. Our physicians interact with systems like CliniComp, which is deployed in at least 50 percent of the beds in our system, and A4 in the ED.

With the introduction of CareCast for CPOE, however, physicians will be asked to interact with multiple systems. The manner in which diverse applications need to be integrated into a physician's workflow--particularly in the ED and ICUs--became a significant concern for us. We anticipated backlash from physicians for having to execute multiple logon sessions. Given the time-pressured environment, having to search for a patient's record in multiple applications wouldn't be acceptable either.

The rollout of the CDR will address these issues somewhat by providing physicians with an immediate snapshot of patient information across various systems. Yet, in many instances, physicians will still need to logon to the actual individual applications and find the patient's record, resulting in the same frustration. For instance, even when the CDR is fully implemented, it won't contain 100 percent of patient data, such as vital signs, which could be viewed in CliniComp. Similarly, a CDR doesn't contain images.

Therefore, to view radiology results, physicians will have to separately pull up a PACS application. Because the CDR is a read-only tool, physicians can only view information; they can't update or edit it, requiring them to return to the native applications.

To give physicians simultaneous, real-time access to patient information across multiple applications and gain their buy-in, we wanted to arm them with two core capabilities. The first was the ability to maintain what is known as patient context across applications, meaning that when a physician selects a patient in one application, other applications instantly tune to that same patient's information. The second was single sign-on (SSO) capability--one username and password for multiple applications.

Context management was a key consideration in our clinical systems strategy, to enable interoperability between the newly acquired CareCast and the existing CliniComp application. We initially considered providing these capabilities using the IDX Web framework, a portal technology. However, we learned that this would require custom interfacing by the vendors of non-IDX applications in order to be incorporated into the solution. This would translate into a lengthy and costly implementation process and would depend on the willingness of the non-IDX vendors to participate.

Then, we began hearing more about a new healthcare IT standard--the Health Level Seven CCOW standard, aimed at integrating applications at the desktop around a user-centered context subject (i.e., the identity of a patient or a user). We learned that the design of the standard is elegantly simple: Vendors develop CCOW-compliant applications capable of sharing context using tightly defined specifications. Then, the provider organization implements a vendor-neutral context manager responsible for orchestrating context among CCOW-compliant applications across the enterprise.

We determined we would be better served by this vendor-neutral, open approach, because it would allow us to achieve front-end plug-and-play functionality among any applications in our infrastructure--regardless of vendor or technology. We decided to implement the Vergence Context Manager from Sentillion Inc., and started pushing CCOW-compliance from our vendors. What made the Vergence Context Manager a particularly intuitive choice was Sentillion's vision of getting systems to work together at the desktop, and then exploiting that synchronization to address various needs.

The Vergence Context Manager sits on a central network appliance, coordinating systems so they work together at desktops as if they were part of a single, common system. For example, a user logs on once and is immediately logged on to all applications to which he has access. Similarly, a user selects a patient in one application and, instantly, that patient's information is displayed in other applications.

We had also been looking at SSO for three years, but hadn't identified an affordable solution that fit our needs, primarily because traditional SSO solutions don't address context management. Together, the SSO and patient context capabilities permitted by Vergence will enable a "holistic" view of patient data that will never reside in a single application. In addition, these two capabilities will make the use of computer-based patient information seamless and fluid, increasing physician satisfaction and productivity. Physicians won't have to waste time remembering multiple logon IDs and passwords and reidentifying patients.

Because of the easier process, physicians will be more likely to use our new systems--most notably the CPOE system--which will bolster patient safety and outcomes benefits, and deliver a much greater return on our investment. Patient safety will also be augmented by the fact that physicians will be assured they are viewing data on the same patient as they toggle back and forth between applications.

Advancing Security and Privacy

We also are evaluating various solutions to achieve strong authentication--the process of combining two or more authentication mechanisms. Along with implementing Sentillion's authentication solution, we are evaluating products that can supplement and tightly integrate with Sentillion, such as the Identix BioLogon offering.

Enforcing best practices systems security while ensuring ease of access to systems can be somewhat competing goals. Putting strong authentication mechanisms in place can put another layer between end users and the information they need to access. While we don't want to burden end users, we do want to take advantage of the latest technology to uphold best practices security. With the Vergence system, strong authentication and ease of access become complementary, rather than opposing, efforts.

With this solution in place, we expect to reap other benefits we didn't initially anticipate. For example, we believe the visual integration of data permitted by CCOW will negate the need for some back-end integration efforts. Also, our help desk currently receives an estimated 600 calls per month from clinicians for password-related issues. With this solution in place, the number of calls will be significantly reduced. As a result, we can reallocate resources that otherwise would have been devoted to help desk and integration issues.

Tracking access to patient information across our enterprise was another pressing concern. In the future, however, we will implement the Vergence Privacy Auditor, which works with the Vergence Context Manager to centrally monitor who accessed what patient's information, when and in which application. This will help us ensure against confidentiality breaches across the enterprise--such as unauthorized end users accessing a VIP patient's record. Moreover, it will help us achieve patient privacy and confidentiality in line with HIPAA privacy requirements, which take effect next April.

Because CCOW-based context management is critical to the success of many IT initiatives, CCOW compliance is serious business. Applications from most of our current vendors are CCOW compliant, and we won't sign contracts for new products unless they are CCOW compliant. In cases where our current vendors have delayed CCOW compliance, we are considering implementing bridge products from Sentillion that will allow the applications not yet natively CCOW compliant to work with the Vergence system.

It is a commonly held misconception that having best-of-breed solutions means sacrificing having integrated solutions. Undoubtedly, the inability of diverse systems to work together can lead to pervasive problems. However, many progressive industry thinkers are banding together to develop open, standards-based approaches to integration that are attractive to vendors and providers alike. Diverse systems working in harmony to satisfy the needs of end users, management and ultimately, patients, is music to any CIO's ear.

William Spooner is senior vice president and chief information officer of Sharp HealthCare, an integrated healthcare delivery network in San Diego. Contact him at
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Title Annotation:Sharp HealthCare
Author:Spooner, William
Publication:Health Management Technology
Geographic Code:1USA
Date:Oct 1, 2002
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